Chemical Skin Peels

Peeling

Chemical peels use acid solutions to remove, or actively kill off (induce necrosis or denaturing of) a predetermined numbers of the upper layers of skin. Chemical peels have been performed for over 40 years – ever since a Florida beauty therapist revealed the secret ‘fountain of youth’ phenol mixture she used on her clients to improve photo-aged skin, smooth scarred complexions, reduce wrinkle, remove pre-cancerous lesions or generally to ‘freshen up’ a tired complexion.

The depth and effects of a peel on a person’s face is controlled by:

• The chemical used.

• The concentration of the solution.

• The time the solution remains in contact with the skin.

• The preparation of the skin prior to treatment. The depth of peel required depends on the damage the skin shows and the improvement sought by the patient. Sometimes, a combination of peels may be required to achieve the best result. Some patients, for instance, may desire, a deep peel around a very wrinkled mouth but, only a medium or superficial acid peel over their upper face.

Superficial peels

The two main chemicals involved in such peels are glycolic acid and lower concentrations (up to 15 per cent) of trichloracetic acid, or TCA.

Glycolic acid

This is the best for superficial peeling of mildly sun damaged skin or complexions showing the first signs of ageing – very fine lines, general dullness of tone, slightly uneven pigment.

The treatment is usually performed with a 30-70 per cent concentration. As you have read, glycolic acid is naturally derived from sugar cane. It is non-toxic and is not absorbed into the body, so cannot cause any systemic side-effects in the same way as chemicals such as phenol. (Note: toxicity can occur if industrial, rather than pure medical grade glycolic acid is used. The use of cheaper industrial grade glycolic acid in disreputable clinics has been reported.)

Suitable candidates:

For many patients, whatever their skin damage, a light peel provides an easy entry into the world of aesthetic dermatology. Unlike a facial, it offers a real – albeit limited – complexion clearing result. But unlike the deeper acting variety, none of the complications or any of the giveaways: no recovery period, no redness, no marked scaling or skin peeling.

Acne sufferers, too, may benefit from a light peel to: help clear present comedones; prevent the build-up of future ones; even out the irregular pigmentation that often accompanies acne; and help increase the penetration of topical treatment such as Retin-A and antibiotic creams.

What to expect:

A smoother, fresher-looking complexion. It’s the equivalent of a vigorous face scrub, although preferable because it is now thought that even a very light glycolic acid treatment is registered by the dermis which then produces new collagen.

Spot check
Many salons and clinics now offer the so-called lunch-time peels. These very superficial peels offer modest improvements and allow you to go about your normal daily activities because there is no discernible after effect. The only real inconvenience is to your wallet rather than to your schedule as the results are minimal and short-lived.

Because there is virtually no risk of permanent damage, 30 per cent of glycolic acid treatments are performed in salons. Superficial glycolic acid peels are referred to as lunchtime peels’ as people can resume normal activities after treatment.

Glycolic acids work by dissolving the intercellular glue that holds skin cells together thus persuading them to take their leave sooner rather than later. The epidermis then churns out new cells to make up the deficit and the dermis responds by making more collagen and elastin. Biopsies of glycolic acid treated skin show epidermal and dermal renewal.

For best results, three and five light peels are usually prescribed because the effects of each peel are cumulative. Ideally, the peels are repeated at two-weekly intervals to allow sufficient healing between treatments, but not enough time for the stratum corneum to build up a thick barrier of horny cells,

TCA, or trichloracetic acid

This acid used in up to a 15 per cent solution is classified as a superficial peel, but is a marginally ‘deeper’ light peel than glycolic. Originally used to treat warts, TCA is not a natural chemical but a synthesized one, similar to acetic acid, (I.e. vinegar), Even at 15 per cent TCA results in a deeper peel because it works differently. Rather than acting on the intercellular glue, the acid infiltrates the cells, denaturing or coagulating its protein content thereby killing it. As a result, TCA is also very effective in treating mild to moderate pre-cancerous skin lesions such as the small scaly lumps, solar keratoses which glycolic acid won’t completely clear.

Suitable candidates:

Because it can clear away solar keratoses and solar lentigo as well as smoothing out fine lines, TCA is first choice for the light peeling of skins displaying early forms of these sun-induced changes. It’s usually a better option, too, for patients with oily skins and no history of sensitivities, who generally do not have a marked response to glycolic acid, or for patients disappointed by a glycolic acid treatment.

TCA is also useful for treating hands, forearms and necks which because of lack of protection, often display more marked UV-induced changes.

What to expect:

First, the bad news — TCA causes more stinging and burning which lasts longer. You will not be able to go back to work afterwards as you will look uncomfortably sunburnt and your face will be slightly swollen. Thick skin peeling will continue for several days, and while the skin is healing there is a greater risk of infection and/or complication. Now the good news — you can expect a clearer, brighter skin tone, marked smoothing of fine wrinkles and the removal of most of the scaly and dark patches that brought you to us in the first place.

Medium peels

A combination of different chemicals are often used to perform medium-depth peels.

Chemicals used for these peels

• A TCA solution of up to 35 per cent.

• Jessner’s solution (named after Dr Max Jessner who perfected the acid treatment being used by a US beauty therapist). It is a combination of 15 per cent resorcinol, a resin-based solvent, plus 15 per cent of both lactic and salicylic acids which loosen up the intercellular glue and permit the resorcinol to get through to the lower epidermal layers.

• A combination of 50-70 per cent glycolic TCA or Jessner’s solution. Sometimes two chemicals work better than one. For patients who have had a disappointing result from a single mid-depth peel or for those who are suitable candidates for a deep peel but don’t want to go that far, the combination of a glue dissolver and a cell denaturer is often very effective.

Suitable candidates:

If you are displaying the signs of ‘moderate’ photo damage — you have noticeable lines and wrinkles, obvious brown sun spots and perhaps some thickened areas of waxy-looking skin (known as solar elastosis) — your physician will probably suggest a medium-depth peel. Medium peels are also recommended for those left with small, shallow acne scars.

Patients who choose medium-depth peels are often seeking only a moderate improvement in their complexion, and are happy to retain some gentle lines to give the impression of a face ageing gracefully. They also usually have busy lives so like being able to resume a normal day-to-day routine after about five days, albeit with some camouflaging make-up.

What to expect:

From this depth of peel you can expect a marked softening of your deeper lines, possibly the elimination of some finer ones, and a positive evening out of skin tone including the eradication of most of your solar lentigo and solar keratoses. Of course, what most patients want to know is just how many years will be whittled away. Unfortunately, it’s impossible to be precise. Certainly, the acid will sear away many of the visible changes in your complexion that have been developing for years, and, as well as improving clarity on the surface, new collagen will grow in the dermis giving a renewed firmness and resilience.

Your skin should be sufficiently healed within about five to seven days to allow you to wear camouflaging make-up but will not be completely healed before about two weeks.

Spot check
With the arrival of resurfacing lasers, deep chemical peels are becoming increasingly redundant. In fact, I haven’t performed a phenol peel in nearly a decade. They may still be performed by physicians who have been doing them for years or by those who either don’t have access to or have experience of the expensive resurfacing lasers.

Deep peels

Normally two main chemicals are used to perform deep peels.

Chemical solutions used

• 35-50 per cent TCA.

• Phenol.

Suitable candidates:

Deep peels are suggested when the patient has a severe chronic sun damage (actinic degeneration) and is seeking a really radical rejuvenating result. Anyone considering a deep chemical peel must be made aware of the 6-week pre-treatment skin care routine, the pain involved, and the long, difficult and risk-heavy recovery period. Understandably, this immediately eliminates many potential candidates.

The use of the most radical peeling solution, phenol Bfurther limits suitable candidates. It is a corrosive chemical which sears its way through the entire epidermis and most of the dermis and can make a badly damaged complexion smooth again. But, (and it’s a big but), phenol has an as-yet-unexplained but nevertheless well-documented effect of robbing the melanocytes of their ability to produce pigment. Even after regeneration, melanocytes never regain this pigment power. As a result, the complexion of phenol treated patients is often like fine porcelain. For this reason, phenol peels are best performed on very fair people with less pigment to lose. They should never be performed on those with skin types 3 or darker on whom a pallid complexion would sit strangely above a brown body, or indeed on those who, despite our best efforts to persuade them otherwise, insist on gaining a deep tan.

Phenol can also cause irregularities in heart beat and for this reason a patient must be attached to a cardiac monitor during, and for several hours after, a phenol peel. Patients with a history of heart trouble, therefore, are unsuitable candidates for phenol peels.

What you can expect:

TCA can help remove fine to moderate lines. Pre-cancerous lesions will also be removed, as will solar lentigo and some shallow scars.

With phenol, you will get the most radical skin-smoothing result possible: removal of even deep furrows. But the price paid for radical results is high. Phenol peeling involves much pain, an increased risk of complications including scarring, a long recovery period, and the likelihood of permanent loss of skin pigment.

Even the most hard-hearted dermatologist admits that applying high-strength TCA, and especially phenol, is agonizingly painful. Local anaesthesia is frequently sufficient but general anaesthesia is sometimes the preferred method of pain control, This, of course, is also risky. Also phenol can cause heart irregularities. A specialist anaesthetist (a further expense) should always be present to monitor the patient undergoing a phenol peel.

Peeling versus surgery

Many clinics offer chemical or laser peels as an alternative to surgery. In fact, the two procedures offer quite different results. Peeling acts on the skin’s surface and should improve the complexion. Surgery removes excess lax skin and can lift gravity-pulled skin into a new position. However, some laser resurfacing can, to an extent, firm and tone the skin by causing contraction of the bundles of collagen and elastin fibres in the dermis. For some patients, this may indeed produce enough of a ‘lifting’ effect to obviate their desire for surgery. But if there is a lot of slack skin, surgery remains the only option for a radical result. Equally, the end result of surgery can be disappointing if the skin texture is poor. Increasingly, therefore, cosmetic surgeons are following up facial surgery with chemical peels or laser resurfacing procedures to improve the overall final result.

• Combining surgery with lasers or peels is increasingly common practice.

• Minimally invasive procedures such as laser resurfacing, Botulinium toxin (for crow’s feet and forehead lines) and filler injections to deep lines may postpone surgery.